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TL;DR, one of these three phrases needs to be blurted out within 10 seconds of an inpatient specialty team member picking up the phone:
- "There is a patient with [diagnosis] requiring an admission."
- "Im seeking advice regarding [focused clinical question]"
- "Im looking to refer a patient to your outpatient clinic".

There are only three types of phone calls to specialty / subspecialty units that need to be made on an average ED working day. It is the source of lots of tension between ED and inpatient units, and a fertile breeding ground for condescension and belittling towards junior ED staff (often unintentionally) by inpatient specialty registrars.

Imagine you are a busy subspecialty registrar on a ward round. Your on-call phone rings. An unknown voice on the other end starts with: “hi, Im one of the ED doctors. I’d like to discuss a patient. I’ve got a 45yo gentleman with [insert HOPC here]. Ive sent of [insert investigations here]. He is not unstable so i’ve been asked to refer to you by my consultant.” I’ve worked 24 months as an ICU registrar on the other end of the phone receiving calls from ED – believe me it can be really infuriating and a test of patience. Overhearing these calls can be really cringe. That’s what this guide seeks to prevent.

ISBAR is a common communication tool used to ensure efficient communication, but is often implemented incorrectly.

• Identify – politely introduce yourself.
• Situation – this is not the history of presenting complaint. I cannot stress this enough. If you take home nothing from this article, remember this. It is the reason you are making the phone call. As mentioned, there are only three types of phone calls that you would typically make on a working day. Avoid the phrase “I have a patient…”. Your goal is to blurt out one of these three phrases within 10 seconds of them picking up the phone.
  • “There is a patient with [diagnosis] requiring an admission.”
  • “Im seeking advice regarding [focused clinical question]”
  • “Im looking to refer a patient to your outpatient clinic”.
• Background – a *very* brief primer on the situation
• Assessment – your focused clinical assessment.
• Recommendation – what likely needs to be done going forward.

Part 1: Referrals for Admission

At the time the phone call is made, a decision to admit the patient should have already been made by a senior clinical decision maker – This is usually the senior registrar or consultant in charge of the team.

(IDENTIFY) “Hi, my name’s Bob Im one of the doctors calling from ED, is this the [subspeciality] registrar on call?”

(SITUATION) “There is a patient with [diagnosis] requiring an admission.”

(BACKGROUND) “He was [brought in by ambulance / a ‘walk in’] with [five second summary of triage presenting complaint]. This is in the setting of [major comorbidities and system failures]. In ED we have given [treatment].

(ASSESSMENT) “He is [stable / unstable], and the clinical diagnosis of [X] evidenced by [Y]. I dont think it’s [Z] and he has had a [ED investigations] given the differentials.

(RECOMMENDATION) “He would probably benefit from [inpatient service] and further [more inpatient service].

*Very often, the BACKGROUND is optional. The inpatient teams can read your notes if required. A simplified example is as follows:

“Hi, im Bob one of the ED doctors. Is this the Cardiology reg on call? Wonderful. There is a patient with crescendo angina requiring an admission. He technically has moderate risk chest pain evidenced by a HEART score of 6. He is stable and pain free at rest with negative serial trops, but I am concerned that his HEART score does not reflect the worsening angina he has been getting over the past 3 days – from walking 2-4km a day to the shops to getting angina on ambulating around the house. He would probably benefit from an inpatient angiogram.”

Part 2: Seeking subspeciality consult advice

Be very clear about why you are calling. Often, you do not need to give the whole history of presenting complaint and assessment. Questions to inpatient teams are usually quite focused and precise. You need to know the question before calling the team. If you are uncertain about what to do with your patient or have questions about a patient’s disposition (ie. if they need an admission), DO NOT CALL THE INPATIENT TEAM until speaking to a Senior ED Registrar or ED Consultant.

Simple examples of the (SITUATION) in ISBAR. These questions are ALWAYS FRONT LOADED. Never start a consult conversation with a HOPC or assessment. Always get to the point – then flourish the details as requested by the subspeciality reg/consultant.

Your goal is to blurt out a focused question within 10 seconds of the subspeciality team picking up the phone. Examples below:

Infectious Diseases – “Im looking for advice regarding the best antibiotic to give the patient given he has allergies to penicillins and cephalosporins, and presents with severe biliary sepsis”

Cardiology – “I am seeking advice regarding antianginals on a patient with a HEART score of 4 (low-mod risk chest pain) who is experiencing postural symptoms on isosorbide mononitrate.

Paediatrics – “Im seeking advice on the provisioning of rapid rehydration therapy in a child with known gastroparesis and encoparesis from prematurity”

After making your question clear, then only should you provide the remainder of ISBAR.

Infectious Diseases – “he had a rash with cefalexin, and an episode of anaphylaxis requiring an epipen when he was given penicillin as a child. Looking at the antibiogram, I was wondering about meropenem, clindamycin and ciprofloxacin, but have less experience in their use.”.

Cardiology – “he has clinical features of RH failure, and a recent TTE showed a normal LVEF, but marked RA enlargement and severe tricuspid regurgitation. I think vasodilators could cause marked hypotension in this patient.”

Paediatrics – “The mother reports that rapid feeding has caused issues with vomiting and aspiration previously. He is moderately dehydrated, and would likely require 10-20ml/kg of rehydration.”

“What would you suggest?”

The inpatient specialist may ask some questions and do try your best to provide concise answers.

Part 3: Request for Followup / Disposition Planning

This is arguably the easiest phone call to ever make in ED, but requires a reasonable working diagnosis and some idea about the meta/background of the situation. It’s best to illustrate this with examples, at three levels of proficiency:

[Level 1]
There’s a patient in ED with an ankle fracture. Im looking for advice regarding what type of plaster I should apply – a backslab or moon/CAM boot or full cast. Could you please have a look at the xray.

[Level 1]
There’s a patient in ED with an ankle fracture who needs ortho clinic followup. It is not displaced and we have put the patient in a full cast. Could you please have a look at the images and let me know if thats ok?

[Level 3]
There’s a patient in ED with a closed weber B ankle fracture without talar shift. I’ve placed a full POP and would appreciate if you could look at the post POP Xray to see if the alignment is satisfactory for clinic followup in a week.

Unless you are certain, do clarify the working diagnosis with your supervisor before calling an inpatient team for disposition planning. Very often, this makes a 5 minute phone call turn into a 30 second phone call.